1154768133 NPI number — NICOLE ROY PT

Table of content: NICOLE ROY PT (NPI 1154768133)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154768133 NPI number — NICOLE ROY PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROY
Provider First Name:
NICOLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RIPPENTROP
Provider Other First Name:
NICOLE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1154768133
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5050 EL CAMINO REAL
Provider Second Line Business Mailing Address:
210
Provider Business Mailing Address City Name:
LOS ALTOS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94022-1530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-559-0011
Provider Business Mailing Address Fax Number:
650-559-0012

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5050 EL CAMINO REAL
Provider Second Line Business Practice Location Address:
210
Provider Business Practice Location Address City Name:
LOS ALTOS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94022-1530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-559-0011
Provider Business Practice Location Address Fax Number:
650-559-0012
Provider Enumeration Date:
05/30/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  39563 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 39563 . This is a "PT LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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